What you need to know about the latest changes to government healthcare sectors and regulations

By Sydney Spicer and Curtis Humphrey
Mar 23, 2023
For the first time since the onset of the COVID-19 pandemic, the U.S. government will enact changes that impact its biggest healthcare consumers across the Affordable Care Act (ACA), Medicaid, and Medicare. From the evolving face of membership to changing regulations, these shifts can be confusing but will also bring exciting new ideas to the market. Our experts in the industry continue to track the latest changes and trends and how they are likely to impact payers, providers, and consumers.
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The key digital trends shaping healthcare

In the wake of the COVID-19 pandemic, healthcare has shifted drastically. We now find digital trends paving the way for progress within the industry. Trends like telehealth, at-home testing, and wearable biosensors empower consumers to embrace their pandemic-tested autonomy when it comes to healthcare management and decision-making.

After nearly three years of conditions that forced consumers to embrace remote at-home healthcare, many don’t want to let go of the freedom, ease of access, and autonomy that came with pandemic-driven digitization. As a result, the healthcare industry finds itself on the precipice of a consumer-driven, fundamental shift towards a more digital, at-home approach. Three key trends emerge as this shift continues to impact the healthcare landscape: more visits conducted via telehealth, increased availability of at-home testing, and incorporation of wearable or smartphone monitoring.


Prior to March 2020, less than 1% of all healthcare visits were conducted via telehealth. After an early pandemic jump to nearly 50%, we now see the percentage of telehealth visits sitting around 11%—and that is expected to grow over the next few years. Consumer surveys support this expected growth. According to a study from JD Power conducted in 2022, 94% of telehealth users said they "definitely will" or "probably will" utilize telehealth to obtain medical services in the future.

At-home testing

More Americans can complete tests related to ongoing conditions or medical concerns at home, and providers can incorporate the resulting data into their care. William Blair analysts recently stated that “home testing and home collection will fundamentally reshape the diagnostics industry and healthcare in general by providing more testing options.” At-home testing may be especially beneficial to Americans with chronic conditions who require frequent testing, which includes nearly half of Americans or 133 million people.

Wearables and smartphone monitoring

Wearable biosensors and smartphone monitoring are not new to the healthcare scene. In 2022, 45.1% of people in the U.S. used remote patient monitoring devices, and that number is expected to jump to over 70% by 2025. These wearable biosensors enable constant monitoring, going beyond a mere snapshot of the individual’s health to allow for a better understanding of trends, needs, and diagnoses.

These trends come with benefits and costs that must be considered before their use is fully embraced. The most obvious concern about these digital trends is the lack of accessibility and affordability, particularly for those without the skills or ability to use them. Considering this, any progress towards digital, at-home healthcare must consider ease of access for every employed tool. If implemented effectively, digital trends in healthcare can work to increase accessibility and affordability for many individuals—including those who have trouble accessing transportation to doctor’s appointments and those who might have difficulty making an appointment over the phone due to hearing loss, as well as many others. Digital solutions cannot employ a “one-size fits all” approach—they must be inclusive and comprehensive.

The digitization of healthcare, which was moving quickly before the COVID-19 pandemic, has exploded in the past few years. Though this quick change can be intimidating, the beneficial impacts of these trends are substantial for consumers. In embracing these digital trends, the healthcare industry should proceed with enthusiasm and care, keeping consumers’ wants and needs top of mind to ensure better outcomes for consumers and top-line benefits to business stakeholders.

Preparing for the Medicare benefit expectations of a new generation

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The popularity of Medicare Advantage (MA) plans skyrocketed in the last decade. In 2022, 29 million Medicare beneficiaries opted for an MA plan, accounting for 45% of the Medicare-eligible population. Additional forecasts predict Medicare Advantage enrollment will increase to more than 50% of the eligible population by 2025. Studies indicate two main reasons for this trend: extended benefit offerings and overall lower out-of-pocket costs when compared to traditional Medicare. Focusing on these two areas through the lens of those currently eligible for Medicare could be a way for payers to get ahead in the market, but neglecting to look beyond the current Medicare pool and consider the next generation of seniors might prove short-sighted in the long run.

The first Generation Xer will become eligible for Medicare in 2030. Seven years from now, that timeframe could be looked at as a lifetime away or right around the corner. When considering the impact that this new group could have on the Medicare landscape, erring on the side of the latter is advisable. Gen Xers are a vastly different group from those who came before them. This incoming generation is touted as being fiercely independent as well as tech-savvy, valuing excellent service, convenience tools, and access to information and options when it comes to their healthcare. And when it comes to purchasing power, this group puts up big numbers—outspending their Baby Boomer predecessors, especially among luxury-brand categories. This indicates a willingness to pay top dollar when a product or service fits their needs. Accounting for these dynamic differences in demographics will help payers attain a premium position with their next member pool.

So, why is this important? Won’t the growing popularity of MA plans inevitably take hold among this incoming cohort and direct them into the open arms of payers? Probably—but this group is discerning by nature and will use their position to choose what suits them best, a choice that will be well-researched and thoroughly vetted. Here are a few best practices payers should consider implementing now to feel confident they’ll stand up to the scrutiny when Gen Xers come their way:

Start the research now

Comprehensive data analysis as a means to inform benefit offerings may seem obvious, but stark differences between current and future Medicare beneficiaries could translate to a need for further diversification of benefits. Having that information sooner gives a longer runway for planning.

Evaluate digital presence

How informative is the information? Are the convenience items as convenient as promised? Riddles aside, analysis of the information produced by self-service tools will give insight into their ability to meet the needs of the incoming generation. If consumers can shop for a car and filter their matches down to details as specific as the infotainment system screen size, they will likely expect a similar experience when shopping for health insurance.

Ensure CX is top tier

As a so-called “sandwich generation,” many Gen Xers inhabit the role of caregiver to both their children and aging parents, taking on various tasks from scheduling appointments to calling businesses on behalf of those they care for. It’s worth considering that a person’s first interaction with a payer could likely occur long before they are shopping for their own MA plan. Excellent service through great customer experiences now has the potential to influence where they seek their own coverage in the future.

By leveraging these best practices to inform focused, strategic initiatives, payers can feel confident in their position in the ever-changing Medicare Advantage landscape.

Driving accessibility to coverage through Medicare, Medicare Advantage, and the exchanges

Several changes are affecting Medicare Advantage and plans offered through the Federal Exchange markets in 2023, as well as proposed changes for 2024. While the changes differ in specific details, most fall into similar general categories. The intent behind most changes for both populations includes improving access to care and medications, facilitating consumers’ ability to choose the best plan for their needs, addressing plan costs, and furthering the federal government’s objective to establish greater healthcare equity.

The continued growth and evolution of Medicare Advantage

With nearly half of the Medicare population covered by a Medicare Advantage (MA) plan, meeting that demand resulted in a substantial increase in the number of Medicare Advantage plans over the past decade. We see that trend continuing for 2023 as well as significant growth in the number of plans offering coverage for institutional-level care—such as extended stays at nursing homes—which has nearly doubled in the last four years.

In 2023, Medicare Part A deductibles and premiums (for those who pay them) will increase over 2022 levels. At the same time, Medicare Part B deductibles and premiums are marginally lower than in 2022. MA Premiums are slightly lower for 2023, while allowable out-of-pocket maximums have increased.

The Inflation Reduction Act includes a requirement for 2023 that all Medicare Part D plans charge no more than a $35 monthly copayment for insulin products covered on the plan’s formulary. Additionally, the list of vaccines available at no cost to the consumer expanded, and coverage for immunosuppressive medications for consumers who qualify for Medicare due to kidney failure and who had a kidney transplant will extend from the three-year timeframe through the patient’s lifetime. In 2023, both the deductible and out-of-pocket maximum amounts associated with Medicare Supplemental (Medigap) plans increased from 2022 as well.

Most MA plans now offer coverage for telehealth services, with some offering supplemental telehealth benefits for services that do not meet the requirements for coverage under Part B when provided in person.

Some MA plans provide coverage for things that original Medicare doesn't cover, like fitness programs, vision, hearing, and routine dental services. Other benefits for services—including transportation to doctor visits, over-the-counter drugs not covered by Medicare Part D, and services promoting health and wellness—may also be provided. Some of these services are offered for no additional premium, with a trade-off including more restrictive provider networks and greater use of cost management tools, such as prior authorization.

In 2023, the restrictions affecting consumers who qualify for Special Enrollment Periods are loosened to include those who missed their Initial Enrollment Period due to natural disasters, emergencies, and other events.

Changes impacting government health insurance exchanges

The 2023 Notice of Benefits and Payment Parameters Final Rule for the ACA focuses on changes that increase public access to healthcare coverage and services. To accomplish these objectives, rules impacting plan design standardization, provider networks, and cost-sharing amounts are adopted. Qualified Health Plans (QHP) participating in the federally facilitated market must now offer standardized plans for every non-standard plan choice at each metal level (bronze, silver, and gold). These standardized plans allow consumers to more easily compare plan offerings across metal levels and insurers.

In addition, some of these plans are now required to provide more comprehensive coverage at a lower cost than previously available, including some increased services to the consumer prior to meeting their deductibles. To better address underserved populations, the new rules dictate that the minimum percentage of Essential Community Providers included in each plan’s network increase from 20% to 35% in 2023. This change expands the variety of providers available to offer covered healthcare services to low-income and underserved populations.

In 2023, QHPs are also required to inform HHS if telehealth services are included in their Provider networks. HHS does not intend for telehealth services to be utilized in place of in-person visits, and the stipulation that such services cannot be offered to consumers with lower cost-sharing than in-person visits reinforces that stance. Additionally, QHPs must ensure that primary care providers are within specific time and distance parameters from covered consumers to facilitate the consumers’ ability to schedule and keep appointments.

There are several issues impacting the cost of plans available in 2023. User fees will remain at 2022 levels during the 2023 plan year, and the Centers for Medicare and Medicaid Services recommends that user fees be decreased by 0.25% for the 2024 plan year. ACA premium subsidies for qualifying consumers extended through 2022 by the American Rescue Plan Act were scheduled to expire in 2023 but have been extended through 2025 via stipulations in the Inflation Reduction Act. Newly adopted 2023 rules also require that plan limitations on any Essential Health Benefits as outlined in the ACA must be clinically based or be considered discriminatory.

To facilitate enrollment for consumers who are losing Medicaid or CHIP coverage beginning in 2024, CMS is considering the addition of a special enrollment period that would span the 60 days prior to those coverages ending through 90 days afterward. This would help prevent such consumers from experiencing periods in which they are uninsured while waiting for the current annual enrollment period. There is also expected to be an additional requirement in 2024 that limits the maximum appointment wait time a consumer may experience. For instance, a provider may not be allowed to schedule appointments with a patient more than 15 days from the time the appointment is requested. These changes help consumers to access and engage in healthcare solutions that meet their needs and improve outcomes.

Meet the authors
  1. Sydney Spicer, Management Strategy Consultant
  2. Curtis Humphrey, Manager, Business Consulting